Document 6478345

Blackwell Publishing IncMalden, USAJSMJournal of Sexual Medicine1743-6095© 2006 International Society for Sexual Medicine200635923931Original ArticleSurgical Treatment of Vulvar VestibulitisGoldstein et al.
923
ORIGINAL RESEARCH—SURGERY
Surgical Treatment of Vulvar Vestibulitis Syndrome: Outcome
Assessment Derived from a Postoperative Questionnaire
Andrew T. Goldstein, MD,*† Daisy Klingman, MD,‡ Kurt Christopher, MD,§ Crista Johnson, MD,¶ and
Stanley C. Marinoff, MD, MPH**
*Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD;
†
Center for Vulvovaginal Disorders, Washington, DC; ‡Department of Psychiatry, University of Pittsburgh Medical Center,
Pittsburgh, PA; §Department of Obstetrics and Gynecology, St. Luke’s-Roosevelt Medical Center, New York, NY;
¶
Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI; **Department of
Obstetrics and Gynecology, George Washington University School of Medicine, Washington, DC, USA
DOI: 10.1111/j.1743-6109.2006.00303.x
ABSTRACT
Introduction. Vulvar vestibulitis syndrome (VVS) is the most common pathology in women with sexual pain.
Surgery for VVS was first described in 1981. Despite apparently high surgical success rates, most review articles
suggest that surgery should be used only “as a last resort.” Risks of complications such as bleeding, scarring, and
recurrence of symptoms are often used to justify these cautionary statements. However, there are little data in the
peer-reviewed literature to justify this cautionary statement.
Aims. To determine patient satisfaction with vulvar vestibulectomy for VVS and the rate of complications with this
procedure.
Methods. Women who underwent a complete vulvar vestibulectomy with vaginal advancement by one of three
different surgeons were contacted via telephone by an independent researcher between 12 and 72 months after
surgery.
Main Outcome Measures. The primary outcome measurement of surgical success was overall patient satisfaction
with surgery. Additional secondary outcome measurements included improvement in dyspareunia, changes in coital
frequency, and occurrence of surgical complications.
Results. In total, 134 women underwent surgery in a 5-year period. An independent research assistant was able to
contact 106 women, and 104 agreed to participate in the study. Mean duration since surgery was 26 months. A total
of 97 women (93%) were satisfied, or very satisfied, with the outcome of their surgery. Only three patients (3%)
reported persistently worse symptoms after surgery and only seven (7%) reported permanent recurrence of any
symptoms after surgery. Prior to surgery, 72% of the women were completely apareunic; however, after surgery,
only 11% were unable to have intercourse.
Discussion. In this cohort of patients, there was a high degree of satisfaction with surgery for VVS. In addition,
the risks of complications with this procedure were low, and most complications were transient and the risk of
recurrence after surgery was also found to be low. Goldstein AT, Klingman D, Christopher K, Johnson C, and
Marinoff SC. Surgical treatment of vulvar vestibulitis syndrome: Outcome assessment derived from a
postoperative questionnaire. J Sex Med 2006;3:923–931.
Key Words. Vaginal Reconstructive Surgery; Causes and Treatment of Sexual Pain Disorders; Dyspareunia
© 2006 International Society for Sexual Medicine
J Sex Med 2006;3:923–931
924
Figure 1 Vestibular erythema in vulvar vestibulitis syndrome.
Introduction
V
ulvar vestibulitis syndrome (VVS) (vestibulodynia, vestibular adenitis, localized vulvar
dysesthesia) is one of the most common causes of
sexual pain in women [1,2]. Patients with VVS
experience severe introital dyspareunia that is frequently described as burning, cutting, or searing,
upon vaginal penetration. Pain is localized to the
tissue of the vulvar vestibule which is derived from
the primitive urogenital sinus (Figure 1) [3].
Women who have had introital dyspareunia ever
since their first attempt at intercourse (or tampon
insertion) have primary VVS, whereas women
who had an initial interval of pain free intercourse
prior to the onset of symptoms are described as
having secondary VVS. While the underlying
pathophysiology of VVS has not been completely
elucidated, several recent studies have confirmed
a proliferation of c-afferent nociceptors in the vestibular mucosa [4–8]. These studies have shown up
to a 10-fold increase in density of nerve endings
in the vestibular mucosa of women with VVS [5].
This neuronal hyperplasia may explain the
extreme allodynia women experience with VVS.
Recent studies have suggested that in some cases,
primary VVS may be the result of a congenital
neuronal hyperplasia in the tissue derived from the
primitive urogenital sinus [9,10]. Additional studies have suggested that secondary VVS may be
caused by nerve growth factor-initiated proliferation of nociceptors mediated by mast cells [5].
J Sex Med 2006;3:923–931
Goldstein et al.
Additional factors such as genetic polymorphisms
in genes, down-regulation of hormonal receptors,
or hormonal alterations caused by oral contraceptive pills may also play a role in the pathogenesis
of VVS [11–14].
There are more than 20 different treatments
reported in the medical literature for VVS, including topical and intra-lesional steroids [15], interferon [16], biofeedback [17], capsaicin [18],
lidocaine [19], intravaginal physical therapy [20],
amitriptyline [21], cognitive–behavioral therapy
[22], acupuncture [23], nitroglycerine [24], and
dietary changes [25]. Safety and efficacy data concerning these treatment regimens are published,
for the most part, in small case series, which are
neither randomized nor placebo-controlled.
Woodruff first described surgery for VVS in
1981 calling it a “modified perineoplasty” [26].
Since that time, there have been 32 different case
series compromising a total of 1,275 patients
(Table 1). These reports represent several different surgical procedures as there have been modifications of the basic excision and reconstructive
procedure. In the original procedure, Woodruff
removed a semicircular segment of perineal skin,
the mucosa of the posterior vulvar vestibule, and
the posterior hymeneal ring. Three centimeters
of the vaginal mucosa was then undermined and
approximated to the perineum.
While there are flaws in the peer-reviewed publications that examine surgery for VVS, 28 of the
32 articles demonstrate at least an 80% success
Table 1 Sexual functioning after vulvar vestibulectomy
surgery
N (%)
Quality of sex life (N = 104)
Much better/better
Same
Worse
Current level of pain during sex (N = 104)
No pain
Discomfort that does not interference with sex
Discomfort that does with interference sex
Apareunia
Sexual activity 3 months prior to surgery (N = 104)
None
1–2 times/month
2–3 times/month
Sexual activity since surgery (N = 104)
None
1–2 times/month
2–3 times/month
Ability to achieve orgasm (N = 104)
Increased
Decreased
No change
91 (87)
11 (11)
2 (2)
54
26
12
12
(52)
(25)
(12)
(12)
77 (74)
20 (19)
7 (7)
12 (11)
34 (33)
58 (56)
10 (10)
9 (9)
85 (81)
Surgical Treatment of Vulvar Vestibulitis
925
rate with surgical management of VVS [27]. Yet,
despite this apparently high success rate, most
review articles and lectures suggest that surgery
should be used only “as a last resort” [28–30].
Risks of complications such as bleeding, infection,
wound dehiscence, hematoma, scarring, increased
pain, unfavorable cosmesis, inhibition of orgasm,
Bartholin’s gland cyst formation, and recurrence
of symptoms are often used to justify these cautionary statement. However, there is very little
available peer-reviewed medical literature to
quantify rates of complications with surgery for
VVS. This information is essential to accurately
counsel women contemplating surgery for VVS.
Materials and Methods
In total, 134 women had vulvar vestibulectomy
with vaginal advancement performed by one of
three different gynecologic surgeons between
October 1, 1997 and October 1, 2003. Women
were considered candidates for surgery if they had
pain limited to the vulvar vestibule. They were
excluded if they had vulvar pain that was not limited to the vestibule (dysesthetic vulvodynia [DV]),
or they had pelvic floor muscle hypertonicity
(PFMH) (pelvic floor dysfunction, vaginismus).
Although the women were not required to have
used conservative treatments prior to surgery, 99
of the 104 women tried at least one conservative
treatment prior to surgery. A woman was considered a candidate for surgery if she, and her surgeon, determined that she was willing and capable
to follow the postoperative care outlined below. In
addition, she had to have at least two thorough
discussions about available conservative treatment
options prior to consenting to surgery. A psychological consultation was not a prerequisite for
surgery.
The procedure performed on all women was a
modification of the original Woodruff procedure.
Modifications of the original procedure were
developed by the three surgeons to minimize complications that have been associated with the original procedure [31]. Specifically, the entire vulvar
vestibule is outlined and then infiltrated with
Marcaine 0.5% with epinephrine for intraoperative hemastasis and postoperative pain control
(Figure 2). The mucosa of the anterior vestibule is
excised even when this area is not painful as this
lowers the chance of postoperative symptom
recurrence. The mucosa of the entire vestibule is
then excised to a point 3 millimeters past the
hymenal ring, thereby removing the entire hymen.
Figure 2 The entire vulvar vestibule is outlined prior to
excision.
The vaginal mucosa is then separated off the
recto-vaginal fascia to create a vaginal advancement flap (Figure 3). The defects in the anterior
vestibule are then closed with 4–0 Vicryl and the
vaginal mucosa is then anchored in an advanced
position with six mattress stitches of 2–0 Vicryl.
These mattress stitches are positioned in an anterior-posterior direction so that the diameter of the
Figure 3 After excising the vestibular mucosa, a vaginal
advancement flap is created.
J Sex Med 2006;3:923–931
926
Goldstein et al.
dential, and that their surgeon would be blinded
to individual responses. A thorough chart review
was performed after contacting individual patients.
Results
Figure 4 The vaginal advancement flap is approximated to
the perineum.
vagina is not compromised. The mattress stitches
minimize the risk of postoperative hematoma, prevent curling of the advancement flap, and minimize the risk of dehiscence of the advancement
flap. The procedure is completed by approximating the vaginal mucosa to the labia minora and
perineum with approximately 20 interrupted
stitches of 4–0 Vicryl (Figure 4). Using interrupted stitches minimizes the risks of hematoma,
wound dehiscence, and postoperative scarring.
All patients applied ice to the perineum postoperatively for 7 days, used Sitz baths for 6 weeks,
and remained on modified bed-rest for 2 weeks.
Six weeks after surgery, the women began vaginal
dilatation with Pyrex dilators.
Patients were contacted between 12 and
72 months after their surgery (mean 26 months).
Patients were contacted by an independent
research assistant via telephone. The research
assistant, a medical student on a research elective,
attempted to contact the patients with telephone
numbers that were in the medical record. If the
telephone numbers were no longer valid, an Internet search engine was used to find current phone
numbers. Of the 134 women who had undergone
surgery in the aforementioned 6-year period, 106
of the women were contacted (79%). An IRBapproved questionnaire was administered by the
independent research assistant after obtaining verbal informed consent (Appendix 1). Participants
were assured that their responses would be confiJ Sex Med 2006;3:923–931
Ninety-one women (87%) reported that their sex
lives were much better or better than before surgery. Eleven women (11%) reported no change in
their sex and two (2%) women reported that their
sex lives were worse since surgery (Table 1). In the
3 months prior to surgery, 77 women (74%) were
apareunic because of severe dyspareunia, and 20
of the remaining 27 women (19%) had intercourse no more than twice monthly. After the surgery, 58 women (56%) were having intercourse at
least three times per month, and only 12 women
(11%) were apareunic. Eighty-five women (81%)
did not have any change in their ability to achieve
orgasm after surgery, 10 women (10%) had an
increased ability to achieve orgasm and nine
women (9%) had decreased ability to achieve
orgasm.
Eighty-seven women (83%) reported no recurrence of symptoms of dyspareunia after surgery,
whereas 10 women (10%) had transient recurrence of dyspareunia, and seven (7%) had permanent recurrence of dyspareunia (Table 2). Ninetyfour women (90%) reported no worsening of
symptoms from the surgery; whereas seven
women (7%) had transient worsening of symptoms and three (3%) had some permanent worsTable 2
Patient satisfaction with surgical outcomes
N (%)
Recurrence of symptoms (N = 104)
Yes—transient
Yes—permanent
No
10 (10)
7 (7)
87 (83)
Symptoms made worse by surgery (N = 104)
Yes—transiently
Yes—permanently
No
7 (7)
3 (3)
94 (90)
Cosmetic changes (N = 104)
Very significant
Significant
Not significant
3 (3)
4 (4)
97 (93)
In retrospect, knowing your results and discomfort of
surgery, would you have surgery again (N = 104)
Yes
No
Unsure
97 (93)
3 (3)
4 (4)
Would you recommend surgery to another
woman with similar symptoms (N = 104)
Yes
No
Unsure
97 (93)
1 (1)
6 (6)
927
Surgical Treatment of Vulvar Vestibulitis
ening of symptoms. Ninety-seven women (93%)
considered the cosmetic results of the surgery to
be insignificant, whereas four women (4%) considered them significant and three women (3%)
considered the cosmetic results to be very significant. Ninety-seven patients (93%) answered that
in retrospect, knowing the discomfort of their surgery, and the results of their surgery, they would
have the surgery again, and would also recommend the surgery to other women with similar
complaints.
No patients had postoperative infection, significant wound dehiscence, or significant scarring.
Table 3
Procedure
Woodruff et al. [26]
Woodruff and Parmley [40]
Woodruff and Friedrich [41]
Peckham [42]
Friedrich [43]
Michlewitz [44]
Bornstein and Kaufman [45]
Perineoplasty
Perineoplasty
Perineoplasty
Perineoplasty
Perineoplasty
Perineoplasty
Perineoplasty
(modified)
Perineoplasty
Modified
vestibulectomy
Vestibuloplasty
Perineoplasty
Modified
vestibulectomy
Vestibulectomy
Perineoplasty
Perineoplasty
Perineoplasty
(modified)
Perineoplasty
Vestibulectomy
Vestibuloplasty
Modified
vestibulectomy
Vestibulectomy
Vestibulectomy
Vestibulectomy
Perineoplasty
Vestibulectomy
Perineoplasty
Modified
vestibulectomy
Vestibulectomy
Perineoplasty
Perineoplasty
Vestibulectomy
Vestibulectomy
Modified
vestibulectomy
Vestibulectomy
Marinoff and Turner [46]
Westrom [47]
Schover [48]
Mann [49]
Barbaro [50]
Abramov [51]
Bornstein [52]
Foster [53]
Chaim [54]
de Jong [55]
Baggish [56]
Goetsch [57]
Kehoe [58]
Weijmar [59]
Bergeron [60]
Bergeron [22]
Bornstein [34]
Berville [61]
Marinoff [62]
Westrom [6]
Kehoe [63]
Hopkins [64]
McKormack [65]
Schneider [66]
Gaunt [67]
Lavy [68]
Total
Discussion
A review of the 32 studies that have examined
surgery for VVS reveals that the surgical success
rate was greater than 80% in 28 of these studies
(Table 3). However, these studies are frequently
criticized because the outcome criteria for “surgical success” are often poorly defined and standard
procedures to assess surgical success are rarely
Review of vestibulectomy studies
Authors
Traas [69]
One patient had a hematoma that required evacuation, and two patients had a Bartholin’s gland cyst
that required in-office marsupialization.
Partial
(significant)
resolution
of pain
No
significant
resolution
of pain
Complete or
significant
reduction in
pain
0
2
6
0
0
0
2
0
15
4
2
100
100
95
100
60
100
90
60
10
11
1
2
1
97
92
1–24
6–54
1–3
18
37
19
14
12
2
6
7
84
88
100
7
11
93
16
12
6
>48
10–70
7
9
51
15
1
31
1
11
1
14
15
12
37
36–84
12
6–72
3–34
3
13
10
22
3
8
2
13
38
22
79
12
107
42
2–36
13–120
6
12
8
3–48
6
7
24
15
60
6
70
33
54
21
42
54
42
59
2–42
NS
12–120
6
6–24
6–120
33
19
16
30
28
39
126
2–264
76
Length of
follow-up
(in months)
Complete
resolution
of pain
18
14
44
9
38†
16
20
6–60
6–36
NS*
NS
NS
NS
6–36
18
12
36
9
23
16
14
73
12
12–36
15–19
38
56
21
Number
of patients
2
11
4
4
43
87
100
89
2
19
4
85
68
68
100
83
82
90
19
15
10
7
6
2
7
9
4
7
89
90
83
83
90
87
37
13
89
19
4
18
5
15
2
14
7
100
91
88
94
1,275
*NS: length of follow-up not stated.
†
Includes 13 patients who had a previous failed surgery performed by another surgeon.
J Sex Med 2006;3:923–931
928
used. In addition, evaluation of success in these
studies is non-blinded, rendering it biased and
highly subjective.
Therefore, this study was designed to address
the aforementioned deficiencies. In this study, several specific outcome measurements were used
to assess surgical success. The primary measure
of success was overall patient satisfaction with
surgery. Additional secondary outcome measurements included resolution or significant
improvement in dyspareunia, increased coital
frequency, and absence of surgical complications.
In this cohort of patients, 93% of patients were
satisfied, or very satisfied, with their surgical outcome. The authors believe that this very high level
of satisfaction was achieved for several reasons. As
with any surgical procedure, patient selection is
extremely important. It has been shown in the
literature that women with active DV and/or
PFMH have a lower surgical success rate [32–34].
Therefore, women with DV or PFMH were not
offered surgery until these concurrent problems
were successfully treated. Forty-three of the 106
women had one or both of these conditions upon
initial presentation, but were successfully treated
for DV or PFMH prior to undergoing surgery. In
addition, modifications of the original Woodruff
procedure described above minimize the risks of
postoperative hematoma, wound dehiscence, and
postoperative scarring. Modified bed-rest for the
2 weeks after the procedure minimizes postoperative complications and aggressive use of vaginal
dilators beginning 6 weeks after surgery prevents
postoperative vaginal stenosis and leads to early
resumption of intercourse.
This study is one of the first to quantify the
risks that are frequently mentioned when discussing this procedure. These data will allow physicians to accurately discuss the risks of this
procedure when deciding on treatment options
with their patients or when obtaining informed
consent for this procedure.
This study was limited because it did not incorporate validated measures of assessing sexual function such as use of the Female Sexual Function
Index and Female Sexual Distress Scale at various
time intervals pre- as well as postoperatively. In
addition, in future studies age-matched controls
with VVS who choose not to undergo surgery
should be compared with women who have surgery along dimensions of sexual functioning and
quality of life measures.
Furthermore, women who made the decision to
undergo surgery may have experienced cognitive
J Sex Med 2006;3:923–931
Goldstein et al.
dissonance reduction and biased scanning in
response to questions on the questionnaire which
elicited whether they would undergo surgery
again knowing the discomforts and surgical
outcomes. The concepts of cognitive dissonance
reduction and biased scanning assume that the
influence of one’s past behavior on future decisions
is mediated by attempts to confirm the legitimacy
of the behavior once one becomes aware of its
occurrence, and this can occur with very little
thought about the behavior in question and the
consequences of engaging in it [35]. Janis and
King [36] first postulated the theory of biased
scanning wherein after people have engaged in a
particular behavior, they often conduct a biased
search of memory for previously acquired knowledge that confirms the legitimacy of their act.
They may then combine their estimates of the
likelihood and desirability of these consequences
to form a new attitude toward the behavior [37],
and this attitude, in turn, might influence both
their intentions to repeat the behavior and their
actual decision to do so when the occasion arises
[35].
The theory of cognitive dissonance assumes
that when people become aware that they have
voluntarily performed a behavior that contradicts
the implications of a previously formed attitude,
they experience discomfort (dissonance) [38,39].
Therefore, they attempt to rationalize their
counter-attitudinal behavior by convincing themselves that they had good reasons for engaging in
it. This rationalization is likely to produce a
change in their estimates of both the likelihood
and desirability of the behavior’s specific consequences and therefore a revision of the attitude for
which these estimates have implications. The new
attitude, in turn, may provide the basis for their
future behavioral decisions [35].
In this study, biased scanning and cognitive
dissonance reduction may have been introduced
in women who underwent vulvar vestibulectomy
with vaginal advancement. Based on these theories,
patients with VVS may still recommend a surgical
intervention for other women in order to create
less dissonance, even if their surgical outcome
may in fact have been either unfavorable or
resulted in no change in their current health status.
Lastly, while there have been several recent
studies showing promising new treatment for VVS
including topical lidocaine [18] and capsaicin [17],
it is not known whether these treatment options
temporize the symptoms of VVS or offer a longterm cure for VVS. As the majority of women with
Surgical Treatment of Vulvar Vestibulitis
VVS are in the third decade of life, it is important
to question the benefit of treatment options that
are palliative rather than curative. Therefore, until
there is evidence that there are other treatments
for VVS that offer cure rates that are comparable
to surgery, vestibulectomy should not be reserved
as a treatment of last resort.
In summary, in this cohort of patients, there was
a high degree of satisfaction with surgery for VVS.
In addition, the risks of complications with this
procedure were low, with most complications
being transient. The risk of recurrence after surgery was also found to be low.
Acknowledgment
This article was presented at the Vulvodynia and Sexual
Pain Disorders, A State of the Art Conference, Atlanta,
Georgia. October 2004.
Corresponding Author: Andrew T. Goldstein, MD,
Center for Vulvovaginal Disorders, 908 New Hampshire
Avenue N.W. Suite 200, Washington, Washington,
DC, 20037 USA. Tel: 202-887-0568; Fax: 410-7578741; E-mail: [email protected]
Conflict of Interest: None declared.
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Appendix 1
Telephone Interview Questionnaire
1. In retrospect, knowing the discomforts of surgery and the results of your surgery, would you
have surgery again? Yes/No/Unsure.
2. Knowing the discomforts of surgery and the
results of your surgery, would you recommend
this surgery to another woman with similar
symptoms? Yes/No/Unsure.
3. In general, is your sex life—much better, better,
the same, or worse, as compared with before
the surgery? Much better/Better/Same/Worse.
4. What is your current level of pain during sex:
0—no pain, 1—discomfort that does not interfere with sex, 2—discomfort that frequency
interferes with sex, 3—unable to have sex? Or
N/A—not in a relationship.
5. Were any symptoms made worse by the surgery? Yes/No. If yes, what were they?
6. In the last 3 months, on average, how many
times did you have intercourse per month?
7. Have you had a recurrence of your symptoms
since having surgery? If yes, what were they and
do these symptoms persist?
8. Has your ability to have orgasm been affected
by this surgery? Increased/Decreased/Same.
9. Would you consider the cosmetic changes associated with the procedure to be: very significant, significant, not significant?
J Sex Med 2006;3:923–931